07 février 2009

Damit der Mensch vor sich Achtung haben kann, muss er fähig sein, auch böse zu sein.



Ivan Aivazovski, Port d'Odessa sur la mer Noire, 1852.


The image of depressive illness dramatically changed between 1960 and 1980. Instead of ‘‘depressive reactions’’ and ‘‘manic-depressive illness’’ the disorders in mood were divided by their association with mania or hypomania into bipolar (with) and unipolar (without) categories. The authors of the recent classification took the theoretical position that most depressive illnesses are on the same continuum of severity. Melancholia became a specifier for the presence of defined signs deemed to characterize a form of depressive illness of high severity. Melancholia was merged into a category that includes any sustained episode of sad mood that substantially affects behavior and functioning. The specifiers psychotic, catatonic, and seasonal were also added to the major depression category as variations of illnesses, rather than as traditional aspects of melancholia.

Other depressive illnesses, such as postpsychotic depression, major depression superimposed upon delusional disorder or schizophrenia, and postpartum depression, were listed separately as if distinct from melancholia. The boundaries between melancholia as a recognizable entity and other depressive states were blurred.

Milder depressive disorders (dysthymia, premenstrual dysphoria, minor depression, and brief depression) were described, based on epidemiologic surveys that reported their presence to be associated with depressive illnesses later in life. A ‘‘subsyndromal’’ depression and a ‘‘characterological’’ depression were oVered as part of a depression spectrum. Substance-induced mood disorder and mood disorder due to a general medical condition and ‘‘not otherwise specified’’ are other options. Other forms of mood disorders were recognized in different DSM sections.

Bereavement became a form of major depression if symptoms persisted longer than 2 months after a loss or the following symptoms were present: guilt ‘‘about things other than actions taken or not taken by the survivor at the time of death,’’ ‘‘thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person,’’ ‘‘morbid preoccupation with worthlessness,’’ ‘‘marked psychomotor retardation,’’ ‘‘prolonged and marked functional impairment,’’ and ‘‘more than transitory hallucinations of the deceased person.’’ These features are consistent with melancholia, however, and do not warrant a
separate classification.
Adjustment disorder with depressed mood is separately listed. It is described as the presence of ‘‘a depressed mood, tearfulness, or feelings of hopelessness’’ that is so severe as to cause ‘‘marked distress’’ and ‘‘significant social or occupational impairment’ occurring within 3 months of an identifiable stressor other than the loss of a loved one (i.e., bereavement). The condition is described as ‘‘chronic’’ if the symptoms persist 6 months after the stressor or its consequences have abated. Severe depressive illness, however, often follows stress and may abate spontaneously by 6 months, and in less time with treatment. Other than not meeting the list criterion for major depression and probably meeting the list, but not the duration, criterion for dysthymia, no justification is offered for separating adjustment disorder from the same spectrum that includes major depression at one end and dysthymia at the other.

Boundaries have been blurred between melancholia and other conditions that share depressive features (e.g., the apathy and motor slowing in some neurologic disease, and low energy, shyness, and anxiety in some personality deviations). This difficulty arises from the vagueness and non-specificity of the diagnostic criteria. All are crosssectional and course of illness is ignored. For example, the diagnosis of major depression requires five or more items in any combination. ‘‘Fatigue or loss of energy’’ and ‘‘diminished ability to think or concentrate’’ are two choices. Severity of the diYculty is not defined; nor is a method of scoring oVered. Surprisingly, depressed mood need not be present for the diagnosis of the depressive illness, as a loss of interest or the ability to experience pleasure is an acceptable alternative. These criteria are also not operationally defined. In the quest for diagnostic reliability, the criteria are oversimplified, thereby lowering the bar for admission into the category of depression.